Ten years ago, physician-assisted dying was legal in Oregon only. It is now legal in Vermont, Colorado, California, Washington, Montana, and the District of Columbia. Moreover, North Carolina is one of several states with pending legislation to legalize it. As the legalization of physician-assisted dying continues to gain momentum across the United States, an increasing number of terminally ill patients will undoubtedly avail themselves of the option. For example, according to the California End of Life Option Act Report, from the time the Act went into effect on June 9, 2016 to December 31, 2016, 258 individuals requested an aid-in-dying drug (ADD drug). This raises a number of questions for health care organizations and medical providers. Below is a summary of the North Carolina bill to legalize physician-assisted dying, followed by some recommendations for the medical community.
In 2017, North Carolina state lawmakers introduced House Bill 789: “End of Life Option Act.” The legislation would allow certain terminally ill patients to end their lives in a “humane and dignified” manner with a physician-prescribed ADD drug. In order for a patient to obtain an ADD drug, a number of conditions would have to be met. (1) The patient must be at least 18 years old. (2) The patient must be a resident of North Carolina. (3) The patient must have the capacity to make medical decisions. (4) The patient must have the physical and mental ability to self‑administer the ADD drug. (5) The patient's attending physician (a North Carolina licensed physician with the primary responsibility of supervising the patient’s terminal illness) must diagnose the patient with an incurable and irreversible disease that will likely result in death within six months. Additionally, a physician who practices separately from the patient’s attending physician is required to confirm the patient’s diagnosis, prognosis, and mental capacity to make medical decisions and verify compliance to the legislation. If it is determined that the patient does not qualify for an ADD drug, the attending physician must submit to the Department of Health and Human Services (DHHS), a written summary of the patient's request for an ADD drug, and the basis for the attending physician’s decision. (6) The patient must request the ADD drug himself/herself twice verbally (at least 15 days apart) and in writing from his/her attending physician directly. The written request, which must be in the requisite format, must be signed and dated by the patient in the presence of two qualified adult witnesses. (7) The patient’s attending physician must initially confirm that the patient’s decision to request an ADD drug is informed and voluntary. The attending physician must again confirm this immediately prior to writing the prescription for an ADD drug. (8) Before prescribing an ADD drug, the attending physician must offer the patient a chance to withdraw his/her request and must inform the patient of the right to change his/her mind at a later date. The attending physician may deliver the ADD drug by either dispensing it directly to the patient or through a pharmacist. (9) The attending physician must advise the patient of the importance of designating a witness to be present when the patient ingests the ADD drug. The attending witness is required to complete a form and return it to the patient’s attending physician upon the patient’s death. Any unused portion of the ADD drug must be properly disposed of after the patient’s death pursuant to the legislation. The patient’s terminal disease should be recorded as the cause of death on the patient’s death certificate, which may be completed by his/her attending physician. (10) The patient’s attending physician must ensure that all documentation and DHHS submission requirements are fulfilled.
If the bill passes, health care entities will first need to decide if they wish to participate in the acts permitted. Health care organizations that choose to participate should ensure that individual providers know that their participation is strictly voluntary. For medical providers who express a desire to participate, management should consider providing them with supplemental education and an opportunity to ask questions. Further, they should draft policies clearly outlining the requirements of the legislation. Health care entities that choose not to participate should make that clear via well-drafted policies as they will not be able to enforce their decision to refrain from participation against any of their employees or independent contractors without notice. They should also keep in mind that although the legislation does not prevent organizations from opting out, it does prevent them from “impeding or interfering” with a patient’s decision to self-administer an ADD drug. Therefore, managing executives will need to be thinking ahead about how they are going to handle certain conflicts that may arise at their facilities as a result.